Risk assessment discovers obstacles to oral health

Risk assessment is the first step in the journey of this partnership–establishing an approach to patient management that promotes learning and supports home oral health practice. This approach requires that the dental provider is knowledgeable about the epidemiology of common oral illnesses. Predictable patient management for home oral health practice is essential for successful outcomes of professional dental care. Knowledge of risk concerns directs the dental professional to identify potential problems and obstacles in the care of the patient which, in turn, points to potential options for management of patient learning and home oral health practice. Approaches to management will be different for different patients depending on the risks discovered in the assessment process. For example, a patient who cooperates with home oral health practice, accepts oral treatment without resistance, and has a dedicated caregiver with a high dental IQ will be able to receive complex treatment plans (eg, fixed prosthetics) with a high probability of success. A patient who is noncompliant, resistant to treatment, or does not have a caregiver providing effective home care would not be a candidate for complex treatment that requires effective daily home management as he or she would be at risk for treatment failure and continued oral illness.

Risk identification begins with a systematic discovery of threats to the patient’s oral health including developmental concerns, health and health care history, and risks within the patient’s home environment. The patient’s environment includes (but is not limited to): caregiver knowledge, attitude and expectations about oral health, caregiver ability to provide the patient daily home care, patient’s access to care, daily health habits (eg, home hygiene practices, dietary controls), social environment (eg, smoking controls, food reward practices), oral hypersensitivity, sensory motor limitations, and behavioral obstacles specific to self care or assisted oral hygiene. This discovery process starts with communication between the caregiver and the dental care team before the clinical examination. A clear estimation of the patient’s risk factors and oral condition can be easily determined through discussion with the caregiver–including a series of very simple questions. Having an open exchange of information also serves to prepare the patient (if possible), the caregiver, and the dental provider about potential behavioral concerns before the clinical examination. This can prevent stressful outcomes and fosters informed consent for patient management. The following protocol can serve as a guide to obtain critical information in preparation for the clinical examination visit:

• Step 1. Preliminary information (via phone or mailed questionnaire) including legal guardianship and medical and behavioral histories. This prepares the dental care team for possible health-related oral problems, behavioral obstacles, and informed consent barriers.

• Step 2. The caregiver and patient interview ensures that the caregiver understands the requirements for oral health, and identifies the patient’s social and cognitive competence and potential response to the examination. Additionally, the caregiver and dental provider have defined expected patient obstacles to the examination, potential clinical findings, and can agree on the approach to care.

• Step 3. The clinical examination will confirm oral illness, treatment requirements, and the options for patient management relative to his or her cooperation and level of cognitive and social function. The identified risks are explained to the patient (if appropriate), the caregiver, and legal guardian. The consequences to both oral and general health and the methods to eradicate or reduce the risk factors are discussed. This supports patient and caregiver learning, and oral home care efforts.

In summary, effective communication with the caregiver (ie, an exchange of information) and observation of the patient before the hands-on examination provides the best opportunity to promote a partnership with the caregiver and the dental care team, begin the foundation for “informed” consent, and achieve a favorable outcome for the patient’s oral health. Additionally, risk assessment provides information important to development of evidence-based care for each patient.

The importance of effective home oral health practice for oral health and dental care of the special needs group

Self or assisted home oral health practice is critical for oral health as it controls growth of common oral pathogens responsible for the common oral infections (caries, gingivitis, bone loss, and oral malodor). Also, oral cleansing provides beneficial oral motor therapy stimulation and massage for oral tissues that is essential for circulation, cellular turnover, and reduction of oral hypersensitivity. Determining this practice and the patient’s oral hygiene status should be a standard of care performed at each patient visit. Specifically, an oral state free of plaque, oral debris, and accretions facilitates the successful delivery of optimal dental rehabilitation (operative, endodontics, periodontal surgery, implantology, etc) and the prognosis of therapy over time. A suggested guide in developing a treatment plan is presented in Table 1 .

The importance of effective home oral health practice for oral health and dental care of the special needs group

Self or assisted home oral health practice is critical for oral health as it controls growth of common oral pathogens responsible for the common oral infections (caries, gingivitis, bone loss, and oral malodor). Also, oral cleansing provides beneficial oral motor therapy stimulation and massage for oral tissues that is essential for circulation, cellular turnover, and reduction of oral hypersensitivity. Determining this practice and the patient’s oral hygiene status should be a standard of care performed at each patient visit. Specifically, an oral state free of plaque, oral debris, and accretions facilitates the successful delivery of optimal dental rehabilitation (operative, endodontics, periodontal surgery, implantology, etc) and the prognosis of therapy over time. A suggested guide in developing a treatment plan is presented in Table 1 .

Table 1

Relationship of patient compliance and oral cleanliness to level of definitive care

Patient Status	Level of Definitive Care
A. Patient presents with clean oral tissues ■ Has effective caregiver support ■ Tolerates oral procedures	Consider all options for comprehensive care based on patient’s cognitive, social needs and activity, neuromuscular and skeletal concerns, caries risk, strategic importance of tooth or teeth, isolation requirements, behavioral obstacles, habits, dietary and medication risks, etc.
B. Patient presents with clean oral tissues ■ Has effective caregiver support ■ Does not tolerate oral procedures C. Patient presents with poor oral hygiene (ie, debris and gingivitis) ■ Does not have effective caregiver support ■ Tolerates oral procedures D. Patient presents with poor oral hygiene ■ Does not have effective caregiver support ■ Does not tolerate oral procedures	Remove sources of pain and infection: ■ Pulp therapy: Pulpotomy of primary molars with carious exposures; consider endodontic therapy for selected adult teeth ■ Restoration therapy ■ Extraction of nonrestorable or pulpally-involved adult teeth ■ Periodontal therapy beyond scaling and root planing considered on a limited basis ■ Consider prosthetics in selected cases only (risk–benefit ratio for the patient) Provider must consider behavioral obstacles, medication, diet, oral hygiene risks and isolation requirements that would compromise operative, periodontal, and prosthetic therapy. The method (ie, patient management) of care must be considered in regard to future prognosis and need for medical immobilization.
To develop an appropriate treatment plan, the provider must consider the following: ■ Patient safety ■ Potential for recurrent infection (gingival, periodontal, caries risk, tooth surface or location). ■ Isolation demands for treatment (technique) ■ Patient movement or behavior (as it affects above)

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